Primary care: No longer the primary choice

A decade ago, discussion in government agencies, national medical organizations, and medical schools emphasized the need to sway medical students and the medical education establishment toward careers in primary care. News outlets decried the disappearance of the "family doctor." Some state governments used financial leverage to persuade state medical schools to commit to increasing the numbers of graduates who would enter residency training in family medicine, internal medicine, and pediatrics.

A decade later, the number of positions offered by family medicine programs in the 2006 residency match has fallen to 2,711-251 fewer positions than were offered only four years ago. In the same period, the number of US students matched to family medicine programs fell by 276.

The impact of this decline is clear at, among other institutions, Duke University School of Medicine, home of one of the oldest family medicine residency programs in the country. Last month, Duke announced that it will close the program, citing a lack of interest among US graduates.

Medical students and residents are, undoubtedly, responding to a variety of forces as they make career decisions: their perception of employment opportunities; the influence of role models and mentorship; and personal interest in providing more specialized care. It is interesting, however, that concern on the part of the public, government agencies, and professional groups regarding the availability of primary care physicians seems to have disappeared. In early June, in fact, the Association of American Medical Colleges issued guidelines calling for promotion of translational and clinical sciences in medical schools and residency training. Their recommendations, which omit mention of primary care, include a call for "implementation of institutional changes to ensure that translational and clinical research training is a cornerstone of the core mission of academic medicine," and "modifying the structure of medical school and residency programs to accommodate research tracks."

Meanwhile, the public and the media don't seem concerned about a shift in the career trajectory of young physicians. Retail enterprises-including Target and Wal-Mart-have begun to take advantage of the public's diminishing demand for a single primary care physician to call their own by opening health outlets in their stores that are staffed by nurse practitioners and that offer rapid, simple diagnostic testing and treatment without the wait or the complexity that can be involved in a visit to a primary care physician.

All this activity suggests that our system of delivering primary care isn't meeting the perceived needs of the public. No question: Advances in science and translational research deserve the attention of the medical community, and clinicians will have to be trained to take advantage of those advances. In the meantime, we would do well to listen to parents and patients who apparently feel that having access to the services of their pediatrician is somehow just not worth the trouble.